Updated: 12/25/2021

Necrotizing Enterocolitis

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  • Snapshot
    • A 1-month-old boy is brought to the emergency department by his mother due to vomiting after feeds and blood in stool. The patient was born to a 28-year-old woman at 28 weeks gestation. His weight was 989 grams at the time of delivery and had a 5-minute APGAR score of 6. On physical examination the patient appears lethargic and abdominal distension is appreciated. An abdominal radiograph is shown.
  • Introduction
    • Clinical definition
      • acute neonatal intestinal necrosis
  • Epidemiology
    • Incidence
      • 0.1% of all live births
    • Demographics
      • more common in males
    • Risk factors
      • infants born ≤ 35 weeks gestation especially with
        • a birth weight < 1000 g
      • early-onset neonatal sepsis
      • mechanical ventilation
      • 5-minute APGAR < 7
  • ETIOLOGY
    • Pathogenesis
      • although the pathogenesis is unclear, it is believed to be due to an exaggerated inflammatory response to some sort of insult (e.g., enteral feeds in a premature infant) that injures
        • immature intestinal epithelial cells
    • Associated conditions
      • prematurity
  • Presentation
    • Symptoms
      • feeding intolerance (e.g., emesis)
      • lethargy
      • apnea
      • dyspnea
        • may require ventilatory support
    • Physical exam
      • abdominal distension
      • blood in stool
  • Imaging
    • Radiography
      • view
        • abdominal in the supine position
      • indication
        • abdominal radiagraphy is used to confirm the diagnosis of suspected necrotizing enterocolitis
      • findings
        • findings suggestive of necrotizing enterocolitis include
          • pneumatosis intestinalis (hallmark of the disease)
          • hepatobiliary gas
          • pneumoperitoneum
  • Studies
    • Labs
      • complete blood count (CBC)
        • thrombocytopenia is often found and can suggest
          • worsening disease progression if they are declining
      • serum chemistry
      • blood culture
    • Diagnostic criteria
      • the diagnosis is based on abdominal radiographic findings (e.g., pneumatosis intestinalis) and characteristic clinical findings such as
        • abdominal distention
        • rectal bleeding (the bleeding can be occult or grossly present)
  • Differential
    • Spontaneous intestinal perforation
    • Infectious enteritis
  • Treatment
    • Conservative
      • supportive care
        • indication
          • this is the initial medical management of patients with necrotizing enterocolitis
        • modalities
          • intravenous fluid administration
          • discontinuation of enteral feeds
          • total parenteral nutrition (TPN)
    • Medical
      • intravenous broad-spectrum antibiotics
        • indication
          • administered after appropriate samples are obtained for culture
        • modalities
          • an example of medications used for necrotizing include
            • ampicillin, gentamicin, and metronidazole
    • Operative
      • abdominal surgery
        • indication
          • an absolute indication for abdominal surgey is intestinal perforation
        • technique
          • exploratory laparotomy with bowel resection
          • primary peritoneal drainage
  • Complications
    • Bowel perforation
    • Disseminated intravascular coagulation
    • Infectious complications (e.g., peritonitis)
  • Prognosis
    • 15-30% overall mortality and increased mortality with
      • prematurity
      • low birth weight
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